Neurological Physical Therapy Evaluation
Patient Information
Name
Date of Birth
Medical Record #
Date of Evaluation
Referring Physician
Diagnosis & Medical History
Medical Diagnosis
Medical History
Current Medications
Precautions / Contraindications
Subjective Information
Patient Complaint / Symptoms
History of Present Illness
Functional Limitations
Social/Family/Work History
Objective Examination
Mental Status
Communication/Cognition
Pain Assessment
Orientation
Alertness
Memory
Sensation
Reflexes
Tone (spasticity, rigidity, hypotonia)
Range of Motion (ROM)
Strength
Coordination
Balance
Posture
Gait
Functional Mobility
Cranial Nerves
Vision/Hearing
Other Assessments
Assessment
Summary of Findings
PT Diagnosis
Prognosis
Goals
Short Term Goals
Long Term Goals
Treatment Plan
Interventions / Recommendations
Frequency / Duration
Equipment / Orthotics Needed
Referrals (if any)
Therapist Name
Date